45 PRINCE ST - BUILDING INSPECTION ^1
L The Commonwealth of Massachusetts
�< Board of Building Regulations and Standards CITY OF
SALEM
\f\ Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For'Official Use Only.
Building Permit Number: Date Applied:;.
t /lee .0071
Building Official(Print Name) :.Signature, G Date
SECTION L SITE INFO RINIATION. -
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
y ��INGE 577
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1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private ❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2:,` PROPERTYOWNERSHIP''
2.1 wnert of Record:
fZhNGi e�- G2/ZGCL�
Name(Print) City, State,ZIP
�j p/Z/n/Gr STTz/�5/57—
/Z 34) - G 77 b 3d l
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) IE Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units_ I Other E-gpecify:
Brief Description of Proposed Work':_ BCOGsr A00f 'rG Ar`f!G 0XIfT%/✓ 2 X`I /6 0.e. WA1
Al 2.VD• F/M ANp 47"T14 A t-26,4 . t2e/NO4,-G Fw[rr1'A i rr ini i17T>G• 6
vr+6 f ell/ vCA/7- AsreMet.-r 8h61':Pi Aivv INSTd! 2 Gr`Z pUT'l r.
N 6/ i 5 M bit G H .✓rJ Pllz• To bTt'fG
SECTION 4: ESTIMATED CONSTRUCTION COSTS-,
Item Estimated Costs: Official Use Only,
Labor and Materials
I. Building S g Epp yo E Building Permit Fee $ Indicate how fee is determined:
Electrical $ �o ❑ Standard,.CityYPovyn application Fee
2 3�d. ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing S 54'O• no 2. OtherFees: $
1. Nlechanical (FIVAC) S List:
i. Mcchanical (Fire $
-Suppression) Total All Fees: $
6, l'otal Project Cost. S CJ ZV,io
Check No. Check Amount: Cash Amount:
❑ Paid in Full ❑ Outstanding Balance Due:
r '
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
�/j�-�jr�7S (p,vs1321/li�bi•.� /iL L License Numbcr Expiration Date
Name of CSL holder
List CSL Type(see below)
Type - Description
No. and Street
U Unrestricted Buildin s u to 35,000 cu. ft.)
_ Z ! �' �ZI�i� R Restricted 1&2 Family Dwelling
Cityrrown, State, ZIP 'IV, Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
5Xg 93 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /(f 15'Pj )
(=R4t✓gq f!v �OS _ HIC Registration Number E.epir;tion Date
HIC�Company Name gr I-IIC Registrant Name
_!'i'L {NI N�✓[S!r.�eMG r S- eS. pur+,ris�.�7GMei I.eD.-v
No. and Street _ Email address
r/N,B S C I i �� �2 1$
City/Town, State, ZIP Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
�f2/IvU�LO Z 1 /3
Paint Owner's Name(Electronic Signature) ate
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in t appli true and accurate to the best of my knowledge and understanding.
z 2.t 13
Print Owner's.or Authorized Agent's :mie(Electronic Signature) Data
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the [ionic Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under Ni.G.L. c. 142A. Other important information on the MC Program can be found at
www mass.,ov uca Information on the Construction Supervisor License can be found at www.mass.�o�.2d/dL
2. When substantial work is planned, provide the information below:
Total floor area(Sq. ft.) _(including garage, finished basemenb'attic.s, decks or porch)
Cross living arca(s(I. ft.) _ _ I-fabitable room count
Nuniber of tirepLtces_ Number of bedrooms - —_--
Number of bathrooms _ Number of halt/baths
fype of boating system _-- Number of decks/ porches -
1'ypeof cool ing System_-- -- Enclosed-_" __---Open-
i. 'focal I'roject Square Footage' miry be substituted t�)r''fr,tnl Project Coat"
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CITY OF SMZAv1, i�L- sS kCHCSFTTS
' BUILDING DEPiIMLENT
120 WASHLYGTON STREET, 3'o FLOOR
T FL (978)745.9595
FAx(978) 140-9846
KI\BFRi RY DRISCOLL
ArMLYOR Ttioms ST.PIE.aRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO\L\IiSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Piumbers
Appllcant infirrmation Please Print Legibly
/�
V;]ntt:(Oufitw.yOretni:ari°nitndividuat): 0yRls^�f GINS ! R•(/GJ�C�^y L(��
Address: r-1 �/iNr✓Et/Agt�t�F ST�,%T
City/state/Zip: U �MA ' ®ZllrO Phone#: 1J/17
Are you an employer?Check the appropriate.,box:: Type of project(required):
1.0 I am a employer with 4. Lvlt am a general contractor and 1 6. ❑Now construction
employees(Ml and/or part-titne).e have hired the subcontractors
2.0 1 am a sole proprietor or partner. listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These subcontractors have V. (]Demolition
working fur me in any capacity*
workers'comp.insurance. 9, 0 Building addition
(No workers'comp. insurance 5. 0 We are a corporation and its
required,) officers have exercised their 10.0 Electrical repairs or additions
J.0 I am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.(No workers'camp. c. 152,$1(4),and we have no 12.0 Roof n pairs
insurance required.)1 employees.LNo workers' IJ.00ther
camp.insurance required.)
•Any uppik ua du1 chwka box el mull also ell out the teetiuo below showing their walkers'compensation valley intla mutton.
'1 hnnauwncm who submil this affidavit indicating they an doing all work and thin hire"isidecontraetm coati submit anew affidavit indicating%"IL
:Cwm uln,that check this box most aaachod an addiliund what showing the namo of the rsb•CanlHelors and their workers'comp.policy Intomuni".
fain ars euployer that is providing workers'comparmdon lorumnee jot my employers: Below Is the polley and Jab site
injoraradom AA /��/
InsuranccCompanyName: /—G�IL;7LG{' ..1/•iflil'LjYG�� � . / z" crrolrzol �•
Policy 4 or Scif-ins. Liat0: Wr�� /��'G. )�151� Expiration Date:: / A
Job Site Address: qi l N� 7l' City/Statr/2ip: ' A41 m l MA • I-11091 T-V
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 23A of MOIL e. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil prinaatius in the farm of it STOP WORK ORDER and a line
of up to$2M.00 a day against the violator. Ile advised that a copy of this statement may be Purwarded to the Oftiea of
Investigutions ul'lhd DIA fur insurance coveralls verification.
l Jo hereby cerdftltl the pa(asw�rJ pens/tlet o/per/ury/flat the la1fararwlon provided above is true and correct
3i' .i t p ' Z [)aid: 2- c
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Pt•nne,1: /�O 32 8//2
t U/Jicla!use wrly. Do nnf virile he thlr urea, robe completed by city ur lawn o/Jlelud
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City o r lbw n: i
__ __ Permlt/i.lccnse,�
Imulna Authority(circlo one):
I. Board of Health 2.Building Ilepartntent J.Cityfrown Clerk 4, rleetrical bnspector S. Plumbing; inspector
6.Other .. .._
Contact Person:. __... .._ Phonall:
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CITY OF S U E\,I, NLksSACHUSETTS
BUILOL%"G DEPARTNIRIiT
. ^C1,� 130 VU.ISHLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
ciNEBER1 Y DRISCOLL Fn`C(978) 740 9346
A AYOR Tt•tosw ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BUMONG CON12WISSIONER
Construction, Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of tile State Building Code, 730 CMR section l l l.5
Debris, and the provisions of tMGL c 40, S 54;
Building Permit !# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by I IGL c
111, S 150A.
The debris will be transported by:
pr e K— vp TrzriGK
(name of hauler)
The debris will be disposed of in
A VOl Mee,VT C,-6 -�
(name of facility)
(address of 4"'n1re0t`P1:1M1taPP cant
Z 21 13
date
d,bn;.